Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Guidelines for the vaccination of HIV-infected
adolescents and adults in South Africa
Authors:
Sipho K. Dlamini1
Shabir A. Madhi2,3
Rudzani Muloiwa4
Anne von Gottberg5,6
Mahomed-Yunus S. Moosa7
Susan T. Meiring8,9
Charles S. Wiysonge10,11
Eric Hefer12
Muhangwi B. Mulaudzi13
James Nuttall4
Michelle Moorhouse14
Benjamin M. Kagina15,16
Affiliations:
1
Department of Medicine,
University of Cape Town,
South Africa
2
South African Medical
Research Council, Respiratory
and Meningeal Pathogens
Research Unit, Faculty of
Health Sciences, University
of the Witwatersrand,
South Africa
3
Department of Science
and National Research
Foundation: Research Chair:
Vaccine Preventable
Diseases, Faculty of Health
Sciences, University of the
Witwatersrand, South Africa
4
Department of Paediatrics
and Child Health, University
of Cape Town, South Africa
5
Centre for Respiratory
Diseases and Meningitis,
National Institute for
Communicable Diseases,
a division of the National
Health Laboratory Services,
Johannesburg, South Africa
6
School of Pathology, Faculty
of Health Sciences, University
of the Witwatersrand,
Johannesburg, South Africa
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Page 1 of 8 Guidelines
Introduction
The introduction of vaccines has been one of the most cost-effective strategies to prevent infectious
diseases in humans.1 It is estimated that vaccines save 2–3 million lives globally each year (WHO
and UNICEF 2005). Vaccines are critical in preventing vaccine-preventable diseases (VPDs),
particularly among immunocompromised individuals such as those with HIV infection. HIV-
infected individuals have impaired host defence (cellular and humoral immunity), and hence
have a greater risk and severity of VPDs than non-immunocompromised populations.2
Effective antiretroviral therapy (ART) has resulted in HIV infection becoming a chronic
manageable illness. Despite ART, systemic inflammation and immune activation persist in HIV-
infected individuals and are associated with adverse health outcomes.3 Furthermore, immune
reconstitution is incomplete following ART initiation, which might include absence of underlying
memory responses previously induced through natural infection or early childhood vaccination.
Vaccination, and possibly revaccination, could be an important complement to ART in preventing
further complications in this population.4
The impact of VPDs in HIV-infected individuals not only relates to the acute phase mortality but
also derives from the high prevalence of these diseases in the HIV population, with effects on
long-term morbidity and mortality.5
Vaccines enhance immunity against infections that may have been compromised following HIV
infection. The benefits of vaccination in HIV-infected individuals must be weighed against its risks.
However, in the absence of severe immunosuppression, the majority of routine vaccines, including
live attenuated vaccines, have been found to be safe for use in HIV-infected individuals.2 At present,
the evidence suggests that vaccination of HIV-infected persons with suppressed viral loads and
nadir CD4+ counts greater than 200 cells/µL has little or no deleterious effect on immune and
inflammatory activation.4,6 The duration of seroprotection for most vaccines has been shown to be
shorter in HIV-infected patients compared to uninfected individuals.7 There are insufficient data to
guide the optimal timing for revaccination or booster vaccination among HIV-infected individuals.8
There are no national guidelines for the use of vaccines for HIV-infected people in South Africa.
Establishment of guidelines could contribute to improving vaccine uptake in this population. The
national guidelines will also help healthcare workers in decision-making towards vaccinating
HIV-infected individuals. The use of vaccines in the HIV-infected is generally safe and causes
no harm among patients with CD4+ counts above 200 cells/µL and with very low viral load
(< 50 copies/mL).9,10 Even among HIV-infected individuals who are severely immunocompromised,
the majority of non-live vaccines are potentially safe, although the immunogenicity and
effectiveness need to be elucidated.
7
Department of Infectious Diseases, Division of Internal Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
8
National Institute for Communicable Diseases, Division of the National Laboratory Services, South Africa
9
School of Public Health, University of the Witwatersrand, South Africa
10
Cochrane South Africa, South African Medical Research Council, Division of Epidemiology and Biostatistics, Department of Global
Health, Stellenbosch University, South Africa
11
Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
12
Private Practice, Johannesburg, South Africa
13
Private Practice, Rustenburg Phomolong Medical Centre, South Africa
14
Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
15
School of Public Health and Family Medicine, University of Cape Town, South Africa
16
Vaccines for Africa Initiative, University of Cape Town, South Africa
Corresponding author: Sipho Dlamini, sk.dlamini@uct.ac.za
Dates: Received: 12 Feb. 2018 | Accepted: 09 Mar. 2018 | Published: 23 May 2018
How to cite this article: Dlamini SK, Madhi SA, Muloiwa R, et al. Guidelines for the vaccination of HIV-infected adolescents and adults in
South Africa. S Afr J HIV Med. 2018;19(1), a839. https://doi.org/10.4102/sajhivmed.v19i1.839
Copyright: © 2018. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License.
http://www.sajhivmed.org.za Open Access
 Page 2 of 8
As part of a comprehensive approach to the management
of HIV-infected individuals, the Southern African HIV
Clinicians Society aims to promote the use of vaccines in this
group. Currently, there are no guidelines on the use of
vaccines among the HIV-infected in South Africa.
Furthermore, suboptimal knowledge among HIV-infected
individuals and healthcare providers undermines the use of
vaccines in a population that could otherwise benefit most
from vaccination.
Challenges of vaccination
Challenges faced by the healthcare providers wanting to
vaccinate HIV-infected individuals include, firstly, a lack of
national guidelines and policies. Secondly, vaccines are not
generally available at settings where HIV-infected adults
seek care. Furthermore, cost of the vaccines may be a limiting
factor in the health system which is already burdened by
various other costs. These barriers impact negatively on the
uptake of vaccines among HIV-infected adolescents and
adults.
Rationale for the development of
national guidelines
The epidemiology of HIV disease has changed significantly
in the last 10 years in South Africa. More people with HIV are
living longer as access to ART increases. Associated with this
increase in life expectancy is an increased risk of VPDs
despite suppressive ART.
Scope of guideline
These national guidelines for vaccines available for HIV-
infected adolescents and adults in South Africa have been
developed to address challenges of adolescent and adult
immunisation in the setting of HIV. The guidelines specifically
focus on the most common VPDs in sub-Saharan Africa
among HIV-infected adolescents and adults. The best
available evidence has been used to make recommendations
on the appropriate use of active and passive immunisation in
HIV-infected adolescents and adults.
Influenza vaccines
Influenza is a seasonal viral disease that often leads to a high
morbidity and mortality both nationally and globally.
The mortality from influenza in South Africa is between 6000
and 11 000 deaths every year.11 Individuals who are HIV-
infected have a four- to eight-fold risk of influenza and are
1.5 times more likely to die as a result of this than HIV-
uninfected individuals.12,13 There are several types of licensed
vaccines against seasonal influenza; only the trivalent
inactivated influenza vaccine (TIV) is currently available in
South Africa. Vaccination against influenza has been shown
to be an effective preventive strategy, and many international
immunisation guidelines recommend vaccination against the
seasonal influenza in HIV-infected individuals. Evidence
suggests that HIV-infected individuals may have reduced
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Guidelines
immune responses to influenza vaccines, especially when
CD4+ cell counts are below 200 cells/µL.14 Despite this,
influenza vaccination is effective in preventing influenza
infection and reducing severity of influenza-associated
illnesses among HIV-infected persons.10 Inactivated influenza
vaccines administered to HIV-infected individuals have been
found to be safe with a vaccine efficacy of approximately 75%
in South Africa, despite a relatively modest immune response
as measured by the haemagglutinin inhibition (HAI) assay.15
Similarly, despite low immunogenicity per HAI assay of
influenza vaccine in HIV-infected compared to HIV-
uninfected pregnant women in South Africa, the vaccine
efficacy was 73% against influenza confirmed illness among
HIV-infected women.16 These studies suggest that the
conventional immune read-outs which we use for predicting
vaccine efficacy for inactivated influenza vaccine, that is,
HAI titres ≥ 40, might not be useful and may underestimate
vaccine efficacy in this population.
The influenza season in South Africa is variable. It can start as
early as April or as late as July and lasts between 12 and 25
weeks.17
The panel recommends that the trivalent- or quadrivalent-
inactivated influenza vaccine be administered between
March and May each year to all HIV-infected persons,
irrespective of CD4+ cell count, HIV viral load or pregnancy
status.
Pneumococcal vaccines
Invasive pneumococcal disease (IPD) in HIV-infected
individuals is a significant cause of morbidity and
mortality.18 Even with improved and increased access to
universal ART in South Africa, the relative risk of having
IPD among the HIV-infected is 35–100 times more than
HIV-uninfected individuals.19,20,21 Available evidence from
Africa suggests that pneumococcal conjugate vaccines
(PCV) are effective against the vaccine-type pneumococcal
disease when given to HIV-infected adults.19,20 In South
Africa, PCV has been included in the routine childhood
immunisation programme since 2009. Early post-vaccine
impact data from South Africa showed a 40% reduction in
vaccine-type IPD over non-vaccine-type IPD in HIV-
infected adults, indicating that there is some indirect
protection to unvaccinated adults.22
However, with such a high burden of disease in the HIV-
infected population, there is a need to consider additional or
complementary strategies to prevent pneumococcal disease
in HIV-infected adults. An example would be a combination
vaccine strategy of the 13-valent pneumococcal conjugate
vaccine (PCV13) and 23-valent pneumococcal polysaccharide
vaccine (PPV23). This directly increases protection to
serotypes that are in PPV23 but not in PCV13.
Broadly, there are two types of vaccine available for
use to prevent pneumococcal disease: the pneumococcal
polysaccharide vaccines (PPV) and the PCV. The PPV23 is
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 Page 3 of 8
protective against all-cause pneumonia and pneumococcal
disease in HIV-infected adults, although data vary as to
whether the protective benefit is irrespective of CD4+ count
above a particular threshold, or dependent on HIV viral load
at time of vaccination.23 Results from a randomised placebo-
controlled trial of PPV in HIV-infected subjects conducted in
Uganda found an increase in all-cause pneumonia in the
vaccine arm.24 As a result, some international guidelines do
not recommend vaccination with PPV among HIV-infected
adults with CD4+ counts less than 200 cells/µL. The
immunological and clinical efficacy of PPV23 for HIV-
infected adults, particularly in the absence of ART, remains
controversial.19
A randomised double-blind placebo-controlled trial of PCV7
in HIV-infected adults in Malawi showed that the vaccine
was protective against recurrent IPD.19 Other studies have
confirmed the safety and immunogenicity of PCV13 in HIV-
infected adults.20 The use of PCV in HIV infection is supported
by studies showing prevention of pneumococcal pneumonia
in children and prevention of recurrent IPD in adults.25
The use of either PCVs or PPVs will be a balance between the
resources available to pay for the vaccine and the evidence to
support the use of either of the vaccines or even a combination.
The evidence suggests that the burden of pneumococcal
disease is high in HIV-infected individuals, and vaccination
against pneumococcal disease is an important strategy to
reduce this.26 Globally, various advisory committees on
vaccination differ in their recommendations for vaccination
against pneumococcus.27 As an example, the United States
Advisory Committee on Immunisation Practices (ACIP) and
Infectious Diseases Society of America (IDSA) guidelines
recommend PCV13 followed by PPV23 in HIV-infected
adults; however, the evidence supporting this is limited.25 In
contrast, the British guideline recommends vaccination with
PCV13 only, irrespective of CD4+ count, viral load or ART
use.28 Available evidence suggests that the use of PPV23 or
PCV13 is safe in HIV-infected individuals on ART or with a
CD4+ count greater than 200 cells/µL.8,29
Vaccination against pneumococcal disease should be
recommended for all HIV-infected individuals regardless of
CD4+ count, but ideally when HIV viral load is < 1000
copies/mL.29 This guideline supports the prime-boost
immunisation approach of first vaccinating with PCV13
followed by PPV23 eight weeks later. Alternatively, PCV13
can be used alone if available. For those who are to receive
PPV23 as the primary vaccine, it is suggested that the PPV23
vaccine be given to those who have achieved ART-driven
virologic suppression, regardless of the CD4+ count.
Meningococcal vaccines
Neisseria meningitidis is endemic in South Africa, presenting
as meningococcal bacteraemia or meningitis. HIV infection
is an important risk factor for acquiring invasive
meningococcal disease (IMD), with a relative risk 5–13 times
greater than the general population.30,31,32,33 Epidemiological
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Guidelines
data from South Africa show an increased case-fatality rate
of IMD in HIV-infected patients (20% vs. 11% in HIV-
uninfected patients) that could be explained by their
increased odds of bacteraemia compared to meningitis.33
Currently in South Africa, meningococcal disease is a minor
contributor to mortality among the HIV-infected, when
compared to other infections such as tuberculosis (TB) and
pneumococcal disease.34 However, the availability of effective
vaccines against meningococcal disease should warrant the
use of these vaccines in HIV-infected adults where needed. In
2016, the ACIP added HIV infection as a high-risk condition
for meningococcal disease, based on the growing body of
evidence supporting an increased risk of meningococcal
disease in HIV-infected individuals.30,35 Prospective cohort
studies or case-controlled studies are needed to evaluate this
association and further clarify the level of immunosuppression
at which the increased risk occurs.
Our recommendation is that, where possible, vaccination
should be considered in HIV-infected adults with a CD4+
count above 200 cells/µL. Where resources are limited,
routine meningococcal vaccination of HIV-infected adults
should follow the indications for meningococcal vaccination
for the general population.
The general indications for vaccine are:
• functional or anatomic asplenia
• complement deficiency
• individuals at risk of exposure through travel or work
settings (routine microbiology laboratories)
• individuals living in hostels, or university or college
residences
• individuals at risk through an outbreak, including men
who have sex with men (MSM) who may be exposed to
outbreak strains because of social interactions within the
global MSM community.
Two quadrivalent meningococcal vaccines covering
serogroups A, C, W135 and Y are currently available in South
Africa. One is a polysaccharide vaccine and the other is a
protein-conjugated polysaccharide vaccine. Because of the
hypo-immunity associated with repeated doses of the plain
polysaccharide vaccine, it is recommended that HIV-infected
individuals receive the conjugate vaccine.36 A two-dose
primary schedule (given 8–12 weeks apart) is recommended
to increase the likelihood of a protective primary immune
response. This should be followed by booster doses every
five years. HIV-infected persons should ideally be vaccinated
before their CD4+ cell percent drops to < 25%.37
Pertussis vaccines
There are currently two categories of pertussis vaccines,
namely, acellular and whole-cell vaccines.38 Acellular
vaccines are developed from one or more highly purified
individual pertussis antigens, and whole-cell vaccines are
based on killed Bordetella pertussis organisms. Although
infants below three months of age are at the highest risk of
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death from Bordetella pertussis, current epidemiological
evidence shows that it is an important cause of respiratory
disease in both adolescents and adults.38,39,40 Despite the
availability of vaccines and adequate coverage of childhood
vaccinations, incidence of the disease continues to increase
in adolescents and adults, possibly because of waning
immunity. There are very few studies of adolescent and adult
pertussis in the HIV-infected population, with most of the
data on pertussis coming from children.41 Maternal carriage,
HIV exposure of young infants, and incomplete vaccination
seem to be the most important risk factors for childhood
pertussis. Available evidence indicates that maternal
vaccination offers significant protective benefits to both
mothers and infants.39
Evidence shows that asymptomatic pertussis infection is
more common than symptomatic infection in healthy
adolescents and adults.42 More data are needed to understand
the epidemiology and the burden of pertussis in countries
where HIV/AIDS is endemic. To date, there are no studies
with regard to the immunogenicity or efficacy of pertussis
vaccination in HIV-infected adults. Evidence from studies in
children demonstrates that HIV infection lowers antibody
response following vaccination, and high CD4+ counts at
vaccination improve antibody response.41 With the lack of
data on the burden of disease in HIV-infected adolescents
and adults, the recommendation would be that only pregnant
women, regardless of CD4+ counts or viral load, be vaccinated
(with acellular vaccine) during each pregnancy until there is
more evidence to do otherwise. This is mainly to increase
their antibody levels, so as to enhance transplacental antibody
transfer to their newborns, who are at high risk of pertussis
illness.43
Diphtheria and tetanus vaccines
Recommendations for the use of tetanus and diphtheria
vaccines in HIV-infected adults mirror that for the general
population. Both vaccines are inactivated toxoid and are
therefore safe for use in HIV-infected individuals. Vaccine-
induced immune responses following tetanus vaccination
appear to be similar in both HIV-infected and HIV-uninfected
individuals.44 In contrast, vaccine-induced immune responses
following diphtheria vaccination are lower in the presence
of HIV infection and are influenced by the CD4+ counts.7
Studies show that following primary vaccination with
tetanus and diphtheria vaccines among HIV-infected
children, there is a quick waning of the vaccine-induced
immunity.45
However, as the evidence is lacking on the optimal booster
schedule for HIV-infected adults, the recommendation is
administration of tetanus and diphtheria vaccines at least
every 10 years until more data are available.
Hepatitis A vaccines
Hepatitis A virus (HAV) is the most common cause of acute
viral hepatitis, with approximately 1.4 million clinical cases
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Guidelines
annually.46 The disease burden is most likely underestimated
because of a high incidence asymptomatic infection. The
main route of infection is faecal-oral, and infection is driven
by poor access to safe water and sanitation services. In Africa,
data on HAV infection are limited but the continent is
considered to be a highly endemic setting.47 In such settings,
routine vaccination in childhood is not recommended
because of immunity acquired following natural infection.47
Data from South Africa show that antibodies to HAV in Black
African adults are almost 100% by the age of 20 years,
whereas only 30% – 40% of White adults are positive for HAV
antibodies by the age of 20 years.47
Men who have sex with men are at a higher risk of acquiring
HAV infection with reported outbreaks in some parts of the
world.7,48 The burden of disease in this population group is
1.5–3 times that of the general population especially in the
developed world.49
About 13 studies have reported data on HAV vaccination of
HIV-infected adults.46 All these studies explored the immune
responses to HAV vaccination and reported that the vaccine
is safe and without effect on the clinical progression of
HIV infection among adults on ART.46 Vaccination at higher
CD4+ counts is associated with better vaccine-induced
immune responses. However, given the heterogeneity of the
methodology and study populations, these results should be
interpreted with caution.46
There is no consensus on the benefits of routine vaccination
of HIV-infected adults with HAV vaccines. Advisory groups
such as ACIP and the WHO Strategic Advisory Group of
Experts on Immunisation (SAGE) recommend vaccination
in the presence of other risk factors (medical, behavioural,
epidemiological or occupational risk factors). High risk
groups for HAV infection typically include MSM, injection
drug users, people travelling to or working in countries
with a high or intermediate endemicity of HAV, people
with chronic liver disease (including hepatitis B or C),
bleeding diathesis, immunosuppressed individuals who
have undergone transplantation and contacts of children
arriving from countries with high or intermediate HAV
endemicity.46
We recommend that HAV vaccination should be given if
there are other medical, behavioural, epidemiological or
occupational conditions in addition to HIV infection. The
accepted schedule is two doses separated by 6–12 months.46
Hepatitis B vaccines
Hepatitis B virus (HBV) vaccination is highly recommended
for individuals with HIV infection. Globally, the introduction
of routine HBV vaccination has resulted in a significant
decrease of HBV infection and the overall disease burden.46,50
Co-infection with HBV and HIV is considered endemic in
sub-Saharan Africa, including South Africa. Both viruses
share the same routes of infection, and it is estimated that the
prevalence of chronic HBV in HIV-infected individuals
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ranges from 0.4% to 23% in South Africa.51 The overall global
prevalence of co-infection is around 10%, but this estimate
varies from region to region. The rates of HBV infection
among HIV-infected individuals are estimated to be 20 times
higher than among HIV-uninfected persons.46,52
In South Africa, HBV vaccination has been part of the
childhood immunisation programme since April 1995.
Although vaccination coverage against HBV in childhood is
high,53 many adults born before 1995 were not vaccinated
earlier in life and remain at high risk of HBV infection.54
The administration of vaccines against HBV among HIV-
infected individuals has been shown to be safe in many
studies.55 However, immunologic responses are diminished.46
A successful response to HBV vaccination is most frequently
associated with an undetectable HIV viral load and a CD4+
count above 200 cells/µL.56
The international recommendation for administration of
vaccines against HBV is a four-double-dose regimen of a
recombinant HBV vaccine (40 µg) at 0, 1, 2 and 6 months.57
However, the WHO recommendation is a three-dose regimen
of recombinant HBV vaccine (20 µg) at 0, 1 and 6 months.55
The double-dose regimen induces higher peak anti-HBs
antibody titres than the standard-dose regimen, but no clear
difference in the proportion of adults with protective
antibodies up to five years after vaccination.8,58,59,60 The British
HIV Association (BHIVA) and the ACIP both recommend
serologic antibody testing one month and six to eight weeks,
respectively, following administration of the last dose of the
vaccine.46
The panel supports the four-double-dose regimen HBV
vaccine schedule. If this is not possible, then the standard
regimen should be administered. The panel does not
recommend serologic antibody testing and is only advised
for healthcare workers or others at high risk.
Human papilloma virus vaccines
Human papilloma virus (HPV) infection is a common
infection in HIV-infected adults. The virus is more prevalent
and persistent in HIV-infected adults. The persistence of
certain serotypes of HPV infection is associated with
squamous dysplasia and cancer.61 In 2008, it was estimated
that of the 12.7 million new cancers that occurred worldwide,
around 5% were attributable to HPV infection.61,62 The highest
burden of HPV infection and associated diseases is carried by
women.61,63
HPV vaccines are safe and immunogenic in HIV-infected
adults.64 As observed with other vaccines, HPV vaccine-
induced immune responses are better in HIV-infected
subjects with CD4+ cell counts greater than 200 cells/µL
and suppressed viral loads. There are limited data on the
efficacy and durability of protection provided by HPV
vaccines in HIV-infected adults, whether vaccinated before
or after acquisition of HIV infection. There is also no
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Guidelines
evidence to guide booster vaccine dosing in HIV-infected
individuals.61
In South Africa, HPV vaccination is routinely recommended
for preteen girls aged 9–13 years, regardless of HIV status.
HPV vaccination is recommended for all HIV-infected adult
men and women, and MSM aged up to 40 years, regardless of
CD4+ count, ART use or viral load. In the public sector in
South Africa, the bivalent vaccine is currently in use. In the
private sector, the quadrivalent HPV vaccine (4vHPV) is also
available. The 4vHPV was originally tested and approved as
a three-dose regimen, with a dosing schedule of 0, 2 and 6
months. More recently, a two-dose schedule (6 or 12 months
apart) has been recommended by the World Health
Organization for younger age groups (e.g. 9–14 years at first
dose). This is because immunogenicity with two doses in
preadolescent and early adolescent girls was noninferior to
antibody responses in women aged 16–26 years receiving
three doses.65,66 Should the vaccine schedule be interrupted, it
is recommended that the vaccination series be completed,
rather than restarted.28
Poliovirus vaccines
There are very little data on wild-type poliomyelitis in HIV-
infected individuals. Poliomyelitis is exceedingly rare in
South Africa but continues to occur in a few countries in the
world. The live attenuated oral polio vaccine should be
avoided in immunocompromised HIV-infected individuals
because of the potential risk of paralytic polio.67 Hence, the
inactivated vaccine is recommended.
As with many other vaccines, HIV-infected adults have
reduced vaccine-induced immune response to inactivated
polio vaccine,44,68 which is better if the CD4+ cell count is
above 200 cells/µL.
We recommend that all unvaccinated HIV-infected adults be
vaccinated with the inactivated polio vaccine, regardless of
CD4+ count, especially if the individuals are travelling to
high-risk regions (such as Nigeria, Pakistan and Afghanistan).
Three doses should be administered at 0, 1–2 and 6–12
months with a further dose after 10 years if at high risk.69
Live vaccines
The use of live vaccines is contraindicated in HIV-infected
adults, especially if the CD4+ count is below 200 cells/µL,
and/or there is clinical evidence of acquired immune deficiency
syndrome (AIDS). There is evidence that for some live
vaccines, there is a potential for the proliferation of vaccine-
related viruses in the host, varicella as an example.70,71
Measles, mumps and rubella
vaccine
Measles, mumps and rubella (MMR) vaccines are live and
therefore contraindicated in individuals with CD4+ counts
below 200 cells/µL.
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The ACIP has since 2013 made recommendation about the
use of MMR vaccine in HIV-infected adults, provided the
CD4+ counts are above 200 cells/µL, without laboratory
evidence of immunity or past disease.72 A retrospective study
from the USA assessing the MMR serostatus of HIV-infected
adults reported that 15% of HIV-infected adults are
seronegative. A seronegative MMR status was associated
with a longer duration of HIV infection, younger age and
those born after 1957. This study also reported that about 50%
of HIV-infected adults seroconverted after MMR vaccination.
This study found that MMR vaccination did not lead to
progression of HIV disease, nor did it impact on HIV disease
control.72 This study therefore demonstrated the safety and
efficacy of MMR vaccination in HIV-infected adults with
CD4+ counts above 200 cells/µL and undetectable viral loads.
Most international guidelines recommend MMR vaccination
in non-immune adults infected with HIV with a CD4+ cell
count above 200 cells/µL.28,72
Varicella vaccines
It is estimated that 4.2 million cases of severe varicella
infection globally result in hospitalisation or death. Varicella
zoster virus (VZV) infections and related deaths are common
in HIV-infected individuals. Most HIV-infected adults will
have evidence of prior infection or immunity. There is an
effective vaccine for varicella which is in use in high-income
countries. There are limited data on varicella vaccination in
HIV-infected adolescents or adults, although one study has
reported on the safety and modest immunogenicity of two
doses of varicella vaccine in HIV-infected adults with a CD4+
count above 400 cells/µL with a suppressed viral load.73 At
present in Africa, there is a lack of varicella epidemiology
and socio-economic data on the impact of this disease.
Therefore, there are no data on which to base recommendations
regarding the use of this vaccine in HIV-infected adults.74
Zoster vaccine
Reactivation of latent varicella-zoster virus infection leads to
a debilitating condition: Herpes zoster (HZ; known as shingles).
Despite the increased uptake and use of ART, the incidence of
Herpes zoster remains increased in HIV-infected adults. The
increased uptake of ART has also resulted in a greater
proportion of HIV-infected people living beyond the age of
50 years.7,75,76
The use of varicella vaccine is recommended in varicella-
susceptible adults, as long as they have a CD4+ count above
200 cells/µL; the same CD4+ threshold is used for MMR and
yellow fever vaccines. No transmission of vaccine strain VZV
has been documented in people with HIV infection with
a CD4+ count above this threshold. The administration of
live attenuated Herpes zoster vaccine (LAHZV) to 295 HIV-
infected adults with a CD4+ count above 200 cells/µL was
found to be safe and immunogenic, with no cases of vaccine
strain infection.75,77
At present, there are no epidemiological data to support the
use of this vaccine in Africa. There is a systematic review

TABLE 1: Vaccination guidelines for HIV-infected adolescents and adults.

Vaccine Indication Safety CD4+ count Doses for unvaccinated Booster Comments
adults
MMR vaccine Measles, mumps or ÿ 200 cells/mL 2 doses (28 days apart) Protection likely lifelong Mainly indicated in measles
rubella seronegative seronegative HIV-infected women of
childbearing age
Pregnancy should be avoided for 1
month after vaccination
Influenza R Any 1 dose Yearly -
Pneumococcal R Any 1 dose - Given with PPV23 but must be given first
Conjugated (PCV13)
Pneumococcal RS ÿ 200 cells/mL 1 dose 5–10 years Given with PCV13 but given 8 weeks
after PCV13
Polysaccharide (PPV23) Can be given to patients with CD4 count
< 200 cells/mL if on ART and VL
suppressed
Maximum 2 booster doses, 1 booster
dose in patients > 65 years. Poor
response if CD4+ cell count < 200 cells/
mL and VL not suppressed
Hepatitis B R Any 4 doses (40 µg) Not clear awaiting -
or evidence
3 doses (20 µg)
Hepatitis A RS – travel, MSM, liver ÿ 200 cells/mL 2 doses 10 years -
disease
Meningococcal RS Any 2 doses 5 years -
Tetanus-diphtheria (Td) R Any - 10 years -
Pertussis-acellular R Any 1 dose 10 years Given in pregnancy combined with
tetanus-diphtheria (DTPa/dTpa)
Poliomyelitis-inactivated RS ÿ 200 cells/mL 3 doses none -
Human papilloma virus (HPV) RS – females, MSM Any 2 doses none -
Varicella NR - - - May be considered if CD4+ count > 400
cells/mL
Zoster RS ≥ 200 cells/mL 1 dose none Only use if CD4+ count ≥ 200 cells/µL
MMR, measles, mumps, and rubella; R, recommended; RS, recommended in selected individuals; NR, not recommended; VL, viral load; HBsAb, hepatitis B surface antibody; MSM, men who have
sex with men.

http://www.sajhivmed.org.za Open Access

 Page 7 of 8
underway to assess the morbidity and mortality of VZV
infection.74 Until more evidence becomes available, we do not
recommend this vaccine for HIV-infected adults.
Conclusion
The role out and increased uptake of ART has led to
improvements in mortality of HIV-infected individuals. A
great proportion of individuals are still at risk of vaccine
preventable infections. Vaccines are an important tool in
protecting individuals at risk of vaccine preventable
infections. A suppressed viral load and a CD4+ count above
200 cells/µL improve immunogenicity to vaccines.
These guidelines are primarily aimed to help clinicians who
look after people living with HIV infection. For some
vaccines, there may not be enough local evidence to give
guidance. It is believed that by producing this guideline, the
gaps in our local data will generate research to provide the
necessary evidence. This guideline attempts to take into
account our local epidemiological situation in formulating
our guidance where possible (see Table 1).
Acknowledgements
This work was supported and funded by the Southern
African HIV Clinicians Society and MSD through an
educational grant. The funders had no role in the development
and preparation of the manuscript. Dr John Black, Dr Prashini
Moodley and Dr Karl le Roux were involved in the discussions
at the guideline meeting that guided the development of
these guidelines.
Competing interests
The authors declare no potential conflict of interest.
Authors’ contributions
S.K.D. chaired the meeting for the development of guidelines
for the use of vaccines for HIV-infected individuals, is the
corresponding author and prepared the first draft of the
manuscript. All other authors were involved in the
discussions that guided the development of the manuscript,
contributed to the first draft and reviewed the first draft. All
authors developed the recommendations.
References
 1. Eaton EF, Kulczycki A, Saag M, Mugavero M, Raper JL. Immunization costs and
programmatic barriers at an urban HIV clinic. Clin Infect Dis. 2015;61(11):1726–
1731. https://doi.org/10.1093/cid/civ637
 2. Geretti AM, Doyle T. Immunization for HIV-positive individuals. Curr Opin Infect
Dis. 2010;23(1):32–38. https://doi.org/10.1097/QCO.0b013e328334fec4
 3. Slim J, Saling CF. A review of management of inflammation in the HIV population.
BioMed Res Int. 2016;2016:3420638. https://doi.org/10.1155/2016/3420638
 4. Tan DH, Szadkowski L, Raboud J, et al. Effect of intercurrent infections and
vaccinations on immune and inflammatory biomarkers among human
immunodeficiency virus-infected adults on suppressive antiretroviral therapy.
Open Forum Infect Dis. 2015;2(2):ofv036. https://doi.org/10.1093/ofid/ofv036
 5. Nicolini LA, Giacobbe DR, Di Biagio A, Viscoli C. Insights on common vaccinations
in HIV-infection: Efficacy and safety. J Prev Med Hyg. 2015;56(1):E28–E32.
 6. Kuller LH, Tracy R, Belloso W, et al. Inflammatory and coagulation biomarkers and
mortality in patients with HIV infection. PLoS Med. 2008;5(10):e203. https://doi.
org/10.1371/journal.pmed.0050203
http://www.sajhivmed.org.za
Guidelines
 7. Crum-Cianflone NF, Wallace MR. Vaccination in HIV-infected adults. AIDS Patient
Care STDs. 2014;28(8):397–410. https://doi.org/10.1089/apc.2014.0121
 8. Kerneis S, Launay O, Turbelin C, Batteux F, Hanslik T, Boelle PY. Long-term immune
responses to vaccination in HIV-infected patients: A systematic review and meta-
analysis. Clin Infect Dis. 2014;58(8):1130–1139. https://doi.org/10.1093/cid/
cit937
 9. Ceravolo A, Orsi A, Parodi V, Ansaldi F. Influenza vaccination in HIV-positive
subjects: Latest evidence and future perspective. J Prev Med Hyg. 2013;54(1):1–10.
10. Remschmidt C, Wichmann O, Harder T. Influenza vaccination in HIV-infected
individuals: Systematic review and assessment of quality of evidence related to
vaccine efficacy, effectiveness and safety. Vaccine. 2014;32(43):5585–5592.
https://doi.org/10.1016/j.vaccine.2014.07.101
11. Cohen C, Moyes J, Tempia S, et al. Mortality amongst patients with influenza-
associated severe acute respiratory illness, South Africa, 2009–2013. PLoS One.
2015;10(3):e0118884.
12. Cohen C, Walaza S, Moyes J, et al. Epidemiology of severe acute respiratory illness
(SARI) among Adults and children aged >/=5 years in a high HIV-prevalence
setting, 2009–2012. PLoS One. 2015;10(2):e0117716. https://doi.org/10.1371/
journal.pone.0118884
13. Cohen C, Moyes J, Tempia S, et al. Severe influenza-associated respiratory
infection in high HIV prevalence setting, South Africa, 2009–2011. Emerg Infect
Dis. 2013;19(11):1766–1774. https://doi.org/10.3201/eid1911.130546
14. Kroon FP, van Dissel JT, de Jong JC, Zwinderman K, van Furth R. Antibody response
after influenza vaccination in HIV-infected individuals: A consecutive 3-year
study. Vaccine. 2000;18(26):3040–3049. https://doi.org/10.1016/S0264-410X(00)​
00079-7
15. Madhi SA, Maskew M, Koen A, et al. Trivalent inactivated influenza vaccine in
African adults infected with human immunodeficient virus: Double blind,
randomized clinical trial of efficacy, immunogenicity, and safety. Clin Infect Dis.
2011;52(1):128–137. https://doi.org/10.1093/cid/ciq004
16. Madhi SA, Nunes MC, Cutland CL. Influenza vaccination of pregnant women and
protection of their infants. N Engl J Med. 2014;371(24):2340. https://doi.
org/10.1056/NEJMc1412050
17. McAnerney JM, Cohen C, Moyes J, et al. Twenty-five years of outpatient influenza
surveillance in South Africa, 1984–2008. J Infect Dis. 2012;206(Suppl 1):S153–
S158. https://doi.org/10.1093/infdis/jis575
18. Cohen C, Naidoo N, Meiring S, et al. Streptococcus pneumoniae serotypes and
mortality in adults and adolescents in South Africa: Analysis of national
surveillance data, 2003–2008. PLoS One. 2015;10(10):e0140185. https://doi.
org/10.1371/journal.pone.0140185
19. French N, Gordon SB, Mwalukomo T, et al. A trial of a 7-valent pneumococcal
conjugate vaccine in HIV-infected adults. N Engl J Med. 2010;362(9):812–822.
https://doi.org/10.1056/NEJMoa0903029
20. Lombardi F, Belmonti S, Fabbiani M, et al. Immunogenicity and safety of the
13-valent pneumococcal conjugate vaccine versus the 23-valent polysaccharide
vaccine in unvaccinated HIV-infected adults: A pilot, prospective controlled
study. PLoS One. 2016;11(6):e0156523. https://doi.org/10.1371/journal.pone.​
0156523
21. Meiring S, Cohen C, Quan V, et al. HIV Infection and the epidemiology of invasive
pneumococcal disease (IPD) in South African adults and older children prior to
the  introduction of a pneumococcal conjugate vaccine (PCV). PLoS One.
2016;11(2):e0149104. https://doi.org/10.1371/journal.pone.0149104
22. von Gottberg A, de Gouveia L, Tempia S, et al. Effects of vaccination on invasive
pneumococcal disease in South Africa. N Engl J Med. 2014;371(20):1889–1899.
https://doi.org/10.1056/NEJMoa1401914
23. MacLennan CA, Richter A, Hodson J, et al. Brief report: Immunization of HIV-
infected adults in the UK with Haemophilus influenzae b/meningococcal C
glycoconjugate and pneumococcal polysaccharide vaccines. J Acquir Immune Defic
Syndr. 2016;73(3):287–293. https://doi.org/10.1097/QAI.0000000000001054
24. French N, Nakiyingi J, Carpenter LM, et al. 23-valent pneumococcal polysaccharide
vaccine in HIV-1-infected Ugandan adults: Double-blind, randomised and placebo
controlled trial. Lancet. 2000;355(9221):2106–2111. https://doi.org/10.1016/
S0140-6736(00)02377-1
25. Sadlier C, O’Dea S, Bennett K, Dunne J, Conlon N, Bergin C. Immunological efficacy
of pneumococcal vaccine strategies in HIV-infected adults: A randomized clinical
trial. Sci Rep. 2016;6:32076. https://doi.org/10.1038/srep32076
26. Jones N, Huebner R, Khoosal M, Crewe-Brown H, Klugman K. The impact of HIV on
Streptococcus pneumoniae bacteraemia in a South African population. AIDS.
1998;12(16):2177–2184. https://doi.org/10.1097/00002030-199816000-00013
27. Lee KY, Tsai MS, Kuo KC, et al. Pneumococcal vaccination among HIV-infected adult
patients in the era of combination antiretroviral therapy. Hum Vaccin Immunother.
2014;10(12):3700–3710. https://doi.org/10.4161/hv.32247
28. Geretti AM, Brook G, Cameron C, et al. British HIV association guidelines on the
use of vaccines in HIV-positive adults 2015. HIV Med. 2016;17(Suppl 3):S2–S81.
https://doi.org/10.1111/hiv.12424
29. Iyer AS, Leggat DJ, Ohtola JA, et al. Response to pneumococcal polysaccharide
vaccination in HIV-positive individuals on long term highly active antiretroviral
therapy. J AIDS Clin Res. 2015;6(2):pii: 421.
30. MacNeil JR, Rubin LG, Patton M, Ortega-Sanchez IR, Martin SW. Recommendations
for use of meningococcal conjugate vaccines in HIV-infected persons – Advisory
Committee on Immunization Practices, 2016. MMWR Morb Mortal Wkly Rep.
2016;65(43):1189–1194. https://doi.org/10.15585/mmwr.mm6543a3
31. Miller L, Arakaki L, Ramautar A, et al. Elevated risk for invasive meningococcal
disease among persons with HIV. Ann Intern Med. 2014;160(1):30–37. https://
doi.org/10.7326/0003-4819-160-1-201401070-00731
Open Access
 Page 8 of 8
32. Harris CM, Wu HM, Li J, et al. Meningococcal disease in patients with human
immunodeficiency virus infection: A review of cases reported through active
surveillance in the United States, 2000–2008. Open Forum Infect Dis.
2016;3(4):ofw226. https://doi.org/10.1093/ofid/ofw226
33. Cohen C, Singh E, Wu HM, et al. Increased incidence of meningococcal disease in
HIV-infected individuals associated with higher case-fatality ratios in South Africa.
AIDS. 2010;24(9):1351–1360. https://doi.org/10.1097/QAD.0b013e32833a2520
34. Jafri RZ, Ali A, Messonnier NE, et al. Global epidemiology of invasive meningococcal
disease. Popul Health Metr. 2013;11(1):17. https://doi.org/10.1186/1478-7954-11-17
35. Campos-Outcalt D. Practice alert: ACIP vaccine update, 2017. J Fam Pract.
2017;66(3):166–169.
36. Khatami A, Pollard AJ. The epidemiology of meningococcal disease and the impact
of vaccines. Exp Rev Vaccines. 2010;9(3):285–298. https://doi.org/10.1586/erv.10.3
37. Meiring S, Hussey G, Jeena P, Parker S, von Gottberg A. Recommendations for
the  use of meningococcal vaccines in South Africa. South Afr J Infect Dis.
2017;32(3):82–86. https://doi.org/10.1080/23120053.2017.1359939
38. Pertussis vaccines: WHO position paper – September 2015. Wkly Epidemiol Rec.
2015;90(35):433–458.
39. Nunes MC, Downs S, Jones S, van Niekerk N, Cutland CL, Madhi SA. Bordetella
pertussis infection in South African HIV-infected and HIV-uninfected mother-
infant dyads: A longitudinal cohort study. Clin Infect Dis. 2016;63(Suppl 4):S174–
S180. https://doi.org/10.1093/cid/ciw527
40. Celentano LP, Massari M, Paramatti D, Salmaso S, Tozzi AE, Group E-N. Resurgence
of pertussis in Europe. Pediatr Infect Dis J. 2005;24(9):761–765. https://doi.
org/10.1097/01.inf.0000177282.53500.77
41. Troy SB, Rossheim AE, Hilliard DD, Cunningham TD. Brief report: Seroprevalence of
pertussis infection in HIV-infected adults in the United States. J Acquir Immune
Defic Syndr. 2016;73(3):282–286. https://doi.org/10.1097/QAI.00000000​00001037
42. Ward JI, Cherry JD, Chang SJ, et al. Bordetella pertussis infections in vaccinated
and unvaccinated adolescents and adults, as assessed in a national prospective
randomized Acellular Pertussis Vaccine Trial (APERT). Clin Infect Dis. 2006;
43(2):151–157. https://doi.org/10.1086/504803
43. Dangor Z, Nunes MC, Kwatra G, Lala SG, Madhi SA. Vaccination of HIV-infected
pregnant women: Implications for protection of their young infants. Trop Dis
Travel Med Vaccines. 2017;3:1. https://doi.org/10.1186/s40794-016-0044-7
44. Kroon FP, van Dissel JT, Labadie J, van Loon AM, van Furth R. Antibody response to
diphtheria, tetanus, and poliomyelitis vaccines in relation to the number of CD4+
T lymphocytes in adults infected with human immunodeficiency virus. Clin Infect
Dis. 1995;21(5):1197–1203. https://doi.org/10.1093/clinids/21.5.1197
45. Rosenblatt HM, Song LY, Nachman SA, et al. Tetanus immunity after diphtheria,
tetanus toxoids, and acellular pertussis vaccination in children with clinically
stable HIV infection. J Allergy Clin Immunol. 2005;116(3):698–703. https://doi.
org/10.1016/j.jaci.2005.05.016
46. Mena G, Garcia-Basteiro AL, Bayas JM. Hepatitis B and A vaccination in HIV-
infected adults: A review. Hum Vaccines Immunother. 2015;11(11):2582–2598.
https://doi.org/10.1080/21645515.2015.1055424
47. Franco E, Meleleo C, Serino L, Sorbara D, Zaratti L. Hepatitis A: Epidemiology and
prevention in developing countries. World J Hepatol. 2012;4(3):68–73. https://
doi.org/10.4254/wjh.v4.i3.68
48. Beebeejaun K, Degala S, Balogun K, et al. Outbreak of hepatitis A associated with men
who have sex with men (MSM), England, July 2016 to January 2017. Euro Surveill.
2017;22(5):698–703. https://doi.org/10.2807/1560-7917.ES.2017.22.5.30454
49. Cheng A, Chang SY, Sun HY, et al. Long-term durability of responses to 2 or 3 doses
of hepatitis A vaccination in HIV-positive adults on antiretroviral therapy. J Infect
Dis. 2017;215(4):606–613.
50. Catherine FX, Piroth L. Hepatitis B virus vaccination in HIV-infected people: A
review. Hum Vaccines Immunother. 2017;13(6):1–10. https://doi.org/10.1080/21
645515.2016.1277844
51. Amponsah-Dacosta E, Rakgole JN, Gededzha MP, et al. Evidence of susceptibility
to lamivudine-based HAART and genetic stability of hepatitis B virus (HBV) in HIV
co-infected patients: A South African longitudinal HBV whole genome study. Infect
Genet Evol.2016;43:232–238. https://doi.org/10.1016/j.meegid.2016.05.035
52. Stabinski L, O’Connor S, Barnhart M, Kahn RJ, Hamm TE. Prevalence of HIV and
hepatitis B virus co-infection in sub-Saharan Africa and the potential impact and
program feasibility of hepatitis B surface antigen screening in resource-limited
settings. J Acquir Immune Defic Syndr. 2015;68(Suppl 3):S274–S285. https://doi.
org/10.1097/QAI.0000000000000496
53. Burnett RJ, Kramvis A, Dochez C, Meheus A. An update after 16 years of hepatitis
B vaccination in South Africa. Vaccine. 2012;30(Suppl 3):C45–C51. https://doi.
org/10.1016/j.vaccine.2012.02.021
54. Amponsah-Dacosta E, Lebelo RL, Rakgole JN, Burnett RJ, Selabe SG, Mphahlele
MJ. Evidence for a change in the epidemiology of hepatitis B virus infection after
nearly two decades of universal hepatitis B vaccination in South Africa. J Med
Virol. 2014;86(6):918–924. https://doi.org/10.1002/jmv.23910
http://www.sajhivmed.org.za
Guidelines
55. WHO. Hepatitis B vaccines: WHO position paper – Recommendations. Vaccine.
2010;28(3):589–590. https://doi.org/10.1016/j.vaccine.2009.10.110
56. Landrum ML, Huppler Hullsiek K, Ganesan A, et al. Hepatitis B vaccine responses
in a large U.S. military cohort of HIV-infected individuals: Another benefit of
HAART in those with preserved CD4 count. Vaccine. 2009;27(34):4731–4738.
https://doi.org/10.1016/j.vaccine.2009.04.016
57. Crum-Cianflone NF, Sullivan E. Vaccinations for the HIV-infected adult: A review of
the current recommendations, Part I. Infect Dis Ther. 2017;6(3):303–331. https://
doi.org/10.1007/s40121-017-0166-x
58. Hepatitis B vaccines: WHO position paper – July 2017. Wkly Epidemiol Rec.
2017;92(27):369–392.
59. Ni JD, Xiong YZ, Wang XJ, Xiu LC. Does increased hepatitis B vaccination dose lead
to a better immune response in HIV-infected patients than standard dose
vaccination: A meta-analysis? Int J STD AIDS. 2013;24(2):117–122. https://doi.
org/10.1177/0956462412472309
60. Potsch DV, Oliveira ML, Ginuino C, et al. High rates of serological response to a
modified hepatitis B vaccination schedule in HIV-infected adults subjects. Vaccine.
2010;28(6):1447–1450. https://doi.org/10.1016/j.vaccine.2009.11.066
61. Kojic EM, Rana AI, Cu-Uvin S. Human papillomavirus vaccination in HIV-infected
women: Need for increased coverage. Exp Rev Vaccines. 2016;15(1):105–117.
https://doi.org/10.1586/14760584.2016.1110025
62. Bosch FX, Broker TR, Forman D, et al. Comprehensive control of human
papillomavirus infections and related diseases. Vaccine. 2013;31(Suppl 7):H1–
H31. https://doi.org/10.1016/j.vaccine.2013.10.003
63. Heard I. Human papillomavirus, cancer and vaccination. Curr Opin HIV AIDS.
2011;6(4):297–302. https://doi.org/10.1097/COH.0b013e328347335d
64. Denny L, Hendricks B, Gordon C, et al. Safety and immunogenicity of the HPV-
16/18 AS04-adjuvanted vaccine in HIV-positive women in South Africa: A partially-
blind randomised placebo-controlled study. Vaccine. 2013;31(48):5745–5753.
https://doi.org/10.1016/j.vaccine.2013.09.032
65. Romanowski B, Schwarz TF, Ferguson LM, et al. Immunogenicity and safety of
the HPV-16/18 AS04-adjuvanted vaccine administered as a 2-dose schedule
compared with the licensed 3-dose schedule: Results from a randomized
study. Hum Vaccines. 2011;7(12):1374–1386. https://doi.org/10.4161/hv.7.​
12.18322
66. Garland SM, Kjaer SK, Munoz N, et al. Impact and effectiveness of the quadrivalent
human papillomavirus vaccine: A systematic review of 10 years of real-world
experience. Clin Infect Dis. 2016;63(4):519–527. https://doi.org/10.1093/cid/
ciw354
67. Chitsike I, van Furth R. Paralytic poliomyelitis associated with live oral poliomyelitis
vaccine in child with HIV infection in Zimbabwe: Case report. BMJ. 1999;
318(7187):841–843. https://doi.org/10.1136/bmj.318.7187.841
68. Vardinon N, Handsher R, Burke M, Zacut V, Yust I. Poliovirus vaccination responses
in HIV-infected patients: Correlation with T4 cell counts. J Infect Dis. 1990;
162(1):238–241. https://doi.org/10.1093/infdis/162.1.238
69. Rivas P, Herrero MD, Puente S, Ramirez-Olivencia G, Soriano V. Immunizations in
HIV-infected adults. AIDS Rev. 2007;9(3):173–187.
70. Kramer JM, LaRussa P, Tsai WC, et al. Disseminated vaccine strain varicella as the
acquired immunodeficiency syndrome-defining illness in a previously undiagnosed
child. Pediatrics. 2001;108(2):E39. https://doi.org/10.1542/peds.108.2.e39
71. Maves RC, Tripp MS, Dell TG, et al. Disseminated vaccine-strain varicella as initial
presentation of the acquired immunodeficiency syndrome: A case report and
review of the literature. J Clin Virol. 2014;59(1):63–66. https://doi.org/10.1016/j.
jcv.2013.10.027
72. Singh HK, Chiu YL, Wilkin T. Measles, mumps, and rubella serostatus and response
to MMR vaccination among HIV-infected adults. AIDS Patient Care STDs. 2015;
29(9):461–464. https://doi.org/10.1089/apc.2015.0050
73. Weinberg A, Levin MJ, Macgregor RR. Safety and immunogenicity of a live
attenuated varicella vaccine in VZV-seropositive HIV-infected adults. Hum
Vaccines. 2010;6(4):318–321. https://doi.org/10.4161/hv.6.4.10654
74. Hussey HS, Abdullahi LH, Collins JE, Muloiwa R, Hussey GD, Kagina BM. Varicella zoster
virus-associated morbidity and mortality in Africa: A systematic review protocol. BMJ
Open. 2016;6(4):e010213. https://doi.org/10.1136/bmjopen-​2015-010213
75. Shafran SD. Live attenuated herpes zoster vaccine for HIV-infected adults. HIV
Med. 2016;17(4):305–310. https://doi.org/10.1111/hiv.12311
76. Berkowitz EM, Moyle G, Stellbrink HJ, et al. Safety and immunogenicity of an
adjuvanted herpes zoster subunit candidate vaccine in HIV-infected adults: A
phase 1/2a randomized, placebo-controlled study. J Infect Dis. 2015;211(8):1279–
1287.
77. Benson CA, Hua L, Anderson JW, et al. Zostavax® is generally safe and immunogenic
in HIV-infected adults with CD4 counts ≥200 cells/μL virologically suppressed on
ART: Results of a phase 2, randomized, placebo-controlled trial. The 19th
Conference on Retroviruses and Opportunistic Infections (CROI); 2012 Mar 05–08;
Seattle, WA; 2012.
Open Access